Plan reimbursement claim form 2026

1. Click ‘Get Form’ to open the plan reimbursement claim form in the editor.
2. Begin by entering your Company Name and Employee Name at the top of the form. This identifies who is submitting the claim.
3. Fill in your Phone number, Social Security number, and E-mail address to ensure proper communication regarding your claim.
4. For Dependent Care Expense Claims, list the names of your dependents and specify the period covered by entering the start and end dates.
5. Provide the name, address, and Tax Identification Number of your service provider. Then, enter the total amount incurred for dependent care expenses.
6. Attach any receipts from your daycare provider or have them sign if no receipts are available. Ensure you understand the limits on claims as noted in the instructions.
7. For Unreimbursed Medical Expense Claims, enter the date incurred, name of service provider, expense description, and person for whom the expense was incurred.
8. Finally, sign and date the form to certify that all information provided is accurate before submitting it via mail or fax as indicated.

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